title: The combined effect of chemoprophylaxis with single dose rifampicin and immunoprophylaxis with BCG to prevent leprosy in contacts of newly diagnosed leprosy cases: a cluster randomized controlled trial (MALTALEP study).
abstract: BACKGROUND
  Despite almost 30 years of effective chemotherapy with MDT, the global new case detection rate of leprosy has remained quite constant over the past years. New tools and methodologies are necessary to interrupt the transmission of M. leprae. Single-dose rifampicin (SDR) has been shown to prevent 57% of incident cases of leprosy in the first two years, when given to contacts of newly diagnosed cases. Immunization of contacts with BCG has been less well documented, but appears to have a preventive effect lasting up to 9 years. However, one major disadvantage is the occurrence of excess cases within the first year after immunization. The objective of this study is to examine the effect of chemoprophylaxis with SDR and immunoprophylaxis with BCG on the clinical outcome as well as on host immune responses and gene expression profiles in contacts of newly diagnosed leprosy patients. We hypothesize that the effects of both interventions may be complementary, causing the combined preventive outcome to be significant and long-lasting.
  
  
  METHODS
  Through a cluster randomized controlled trial we compare immunization with BCG alone with BCG plus SDR in contacts of new leprosy cases. Contact groups of around 15 persons will be established for each of the 1300 leprosy patients included in the trial, resulting in approximately 20,000 contacts in total. BCG will be administered to the intervention group followed by SDR, 2 months later. The control group will receive BCG only. In total 10,000 contacts will be included in both intervention arms over a 2-year period. Follow-up will take place one year as well as two years after intake. The primary outcome is the occurrence of clinical leprosy within two years. Simultaneously with vaccination and SDR, blood samples for in vitro analyses will be obtained from 300 contacts participating in the trial to determine the effect of these chemo- and immunoprophylactic interventions on immune and genetic host parameters.
  
  
  CONCLUSIONS
  Combined chemoprophylaxis and immunoprophylaxis is potentially a very powerful and innovative tool aimed at contacts of leprosy patients that could reduce the transmission of M. leprae markedly. The trial intends to substantiate this potential preventive effect. Evaluation of immune and genetic biomarker profiles will allow identification of pathogenic versus (BCG-induced) protective host biomarkers and could lead to effective prophylactic interventions for leprosy using optimized tools for identification of individuals who are most at risk of developing disease.
  
  
  BACKGROUND
  Netherlands Trial Register: NTR3087.
authors.affiliation: Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P,O, Box 2040, 3000, CA Rotterdam, The Netherlands. j.richardus@erasmusmc.nl.
authors.forename: Renate A
authors.initials: RA
authors.lastname: Richardus
authors.forename: Khorshed
authors.initials: K
authors.lastname: Alam
authors.forename: David
authors.initials: D
authors.lastname: Pahan
authors.forename: Sabiena G
authors.initials: SG
authors.lastname: Feenstra
authors.forename: Annemieke
authors.initials: A
authors.lastname: Geluk
authors.forename: Jan H
authors.initials: JH
authors.lastname: Richardus
mesh_terms: D001500:BCG Vaccine / Q000008:administration & dosage* / Q000009:adverse effects / Q000276:immunology; D018890:Chemoprevention; D004359:Drug Therapy, Combination; D006801:Humans; D007918:Leprosy / Q000188:drug therapy* / Q000276:immunology / Q000382:microbiology / Q000517:prevention & control; D009166:Mycobacterium leprae / Q000187:drug effects / Q000502:physiology; D009426:Netherlands; D012293:Rifampin / Q000008:administration & dosage* / Q000009:adverse effects
chemical_list: D001500:BCG Vaccine; D012293:Rifampin